Study Questions:

What is the association between readmission and mortality outcomes among patients hospitalized with heart failure (HF) within a prospective clinical registry associated with the Hospital Readmissions Reduction Program (HRRP)?

Methods:

The study cohort included 115,245 fee-for-service Medicare beneficiaries across 416 US hospital sites participating in the American Heart Association Get With The Guidelines-Heart Failure registry. Data analysis took place from January 1, 2017 to June 8, 2017. Interrupted time-series and survival analyses of index HF hospitalizations were conducted from January 1, 2006, to December 31, 2014, before HRRP implementation (January 1, 2006, to March 31, 2010), during the HRRP implementation (April 1, 2010 to September 30, 2012), and after the HRRP penalties went into effect (October 1, 2012, to December 31, 2014). The main outcome and measures included risk-adjusted 30-day and 1-year all-cause readmission and mortality rates estimated using hierarchical Poisson models with random effects. The study authors used Cox proportional hazards regression models to analyze the effect of the HRRP period on 30-day and 1-year risk-adjusted readmission and mortality rates. For readmission outcomes, they assumed mortality to be a competing risk in the models, and the cause-specific hazards were modeled.

Results:

The mean age of the study cohort was 80.5 ± 8.4 years, 54.6% (n = 62,927) were women, 81.3% (n = 91, 996) were white, and 9.7% (n = 11,037) were black. Both 30-day and 1-year risk-adjusted readmission and mortality rates followed a similar pattern. The 30-day risk-adjusted readmission rate declined from 20% before the HRRP implementation to 18.4% in the HRRP penalties phase (hazard ratio [HR] after vs. before the HRRP implementation, 0.91; 95% confidence interval [CI], 0.87-0.95; p < 0.001), whereas the 30-day risk-adjusted mortality rate increased from 7.2% before the HRRP implementation to 8.6% in the HRRP penalties phase (HR after vs. before the HRRP implementation, 1.18; 95% CI, 1.10-1.27; p < 0.001). There was a significant decline in 30-day all-cause risk-adjusted readmissions in the HRRP penalties phase compared with the pre-HRRP implementation phase (change in slope, −0.039; 95% CI, −0.076 to −0.003). This was accompanied by a significant increase in 30-day risk-adjusted mortality (change in slope in the HRRP penalties phase compared with the pre-HRRP implementation phase, 0.039; 95% CI, 0.024-0.053). The results persisted in the survival analysis after accounting for censoring and competing risk of death for readmissions outcome: the HR for the HRRP penalties phase versus pre-HRRP implementation phase was 0.91 (95% CI, 0.87-0.95; p < 0.001) for 30-day risk-adjusted readmissions, and was 1.18 (95% CI, 1.10-1.27; p < 0.001) for 30-day risk-adjusted mortality. The 1-year risk-adjusted readmission rate declined from 57.2% to 56.3% (HR, 0.92; 95% CI, 0.89-0.96; p < 0.001), and the 1-year risk-adjusted mortality rate increased from 31.3% to 36.3% (HR, 1.10; 95% CI, 1.06-1.14; p < 0.001) after versus before the HRRP implementation.

Conclusions:

The authors concluded that implementation of the HRRP was temporally associated with a reduction in 30-day and 1-year readmissions, but an increase in 30-day and 1-year mortality, and that this may require reconsideration of the HRRP in HF.

Perspective:

Although this observational study does not directly establish the association of change in readmission rate at a given hospital with change in its mortality rate, the findings of this study are of grave concern and should prompt the overseers of the HRRP to call for a moratorium on the current practice of penalties for readmission and long length of stays until more robust data are available.